1. Sti
Doctor Arif Abid

2. SEXUALLY TRANSMITTED DISEASE PRESENTATIONS
Sexually transmitted diseases can present as follows: • Genital ulcers or sores • Urethral discharge • Vaginal discharge • Cervical infection • Lower abdominal pain • Inguinal bubo • Scrotal swelling • Rectal or pharyngeal inflammation

3. Syphilis
Description
Syphilis is a sexually transmitted infectious disease caused by the spirochete Treponema pallidum.
The infection can affect any organ, and may mimic various other diseases, thus it has been called the"great imitator".
If left untreated syphilis can infect and damage the heart, aorta, brain, eyes and bones, and can be fatal.
Syphilis passes through three distinct stages:
primary infectious
Secondary and latent
tertiary stage.

4. History
In the past, syphilis was called the"French Disease" but also known as the Christian Disease
The Great Pox"Cupid's disease," "The Black Lion, and most well- known as lues or lues venereal or venereal plague"
It is believed the disease was introduced to Europe by Columbus after returning from the West Indies, and its spread within Europe was blamed on the frequent wars within the region at that time.

5. Incidence declined after World War II because of penicillin treatment.
The Tuskegee study in 1932 is a dark part of medical and syphilis history, in which in therapy for black men who penic were infected with syphilis was withheld in order to study the short-term and long term effects of the disease.
syphilis has become more common the last 3 decades with the in introduct the acquired immune deficie syndrome (AIDS).

6. Primary Syphilis
Initially, syphilis appears as a cutaneous ulcer or chancre after direct contact with another infectious lesion.
The chancre appears days average 21 days after exposure.
Chancres are usually solitary, but multiple lesions can occur.
Untreated primary chancres resolve in 75% of cases, but the spirochete remains within the host.

7. Secondary Syphilis
Secondary syphilis results from hematogenous and lymphatic spread of the spirochete.
The secondary stage begins approximately 6 weeks after the chancre appears and lasts for 2-10 weeks.
An influenza-like syndrome occurs with mucocutaneous lesions, hepatosplenomegaly, and generalized adenopathy.

8. Secondary Syphilis
The distribution and morphologic characteristics of individual skin lesions vary
Secondary syphilis lesions most commonly manifest as pink 1-2cm scaly atch that become generalized
syphilis in this stage is easily confused with numerous other cutaneous and systemic diseases, and therefore it has been termed the “great imitator"
In addition to the above cutaneous findings, secondary syphilis may manifest as fever pharyngitis, weight loss, headache, meningitis, hepatitis, renal disease, gastritis, colitis, arthritis, keratitis s and uveitis.

9. Latent Syphilis
Latent syphilis is a state of positive serologic tests ( false positive) without evidence of active disease.
It has an early and late status.
The early latent period begins 2 years from the onset of primary disease, without signs or symptoms of disease.
Late latent syphilis is infection with the spirochete greater than 2 years, without clinical evidence of disease.
Early latent syphilis can be treated with one intramuscular injection of long- acting penicillin.
Late latent syphilis requires 3 weekly. injections, but is not as"infectious" as early latent syphilis.
Half of patients in early latent syphilis will progress to late stage syphilis

10. Tertiary Syphilis
Tertiary syphilis is characterized by a small number of organisms eliciting a large or brisk cellular immune response with many clinical manifestations.
Systemic disease develops in about 25% of untreated or inadequately treated cases.
Tertiary syphilis typically develops 1-10 years after initial infection.
Cardiovascular and central nervous system involvement,
with systemic granulomas or gummas are the hallmarks of this stage.

11. Congenital Syphilis
Treponema pallidum can be transmitted from an infected mother to her fetus.
In untreated cases:
25% of neonates are stillborn,
25% die shortly after birth,
10% have no symptoms,
40% will have late symptomatic congenital syphilis.
In early congenital syphilis, rash, hepatosplenomegaly and bone and joint changes occur before age 2 years.
In late congenital syphilis, bone and joint changes, neural deafness and interstitial keratitis occur after age 5 years.
Therapy before the 16th week of gestation usually prevents infection of the fetus. A fetus is at greatest risk when the mother has syphilis for less than 2 years.

12. Skin Findings Primary syphilis
The chancre begins as a papule or nodule, then undergoes ischemic necrosis and erodes and ulcerates
The chancre is usually 3 mm to 2.0cm,
With firm raised sharply defined border
These lesions may be asymptomatic and undetected on the cervix of women, allowing transmission to the other
Painless, hard, discrete, Nonsuppurative regional lymphadenopathy develops in 1-2 weeks,
The chancre heals with scarring, typically in weeks.

13. Skin Findings Secondary Syphilis
This stage of syphilis is characterized by systemic , cutaneous and mucosal signs
Symptoms. Fever, malaise, pharyngitis adenopathy, weight loss and meningeal signs (headache) are common.
The most common sign is a non-pruritic generalized, pink, scaly papular eruption(80%),
The patches develop slowly, appear in a variety of shapes, including round, ellipsoid, oval or annular and last for weeks or months.
symmetric hyperpigmented oval papules with a collarette of scale appear on the palms or the soles in most s patients.

14. Skin Findings Secondary Syphilis ...
Alopecia of the beard, scalp, Irregular and eyelashes occurs which is sometimes referred to as"moth-eaten alopecia".
Whitish, moist, anal condyloma lata lesions are highly infectious wart like papules that are characteristic of syphilis, and may be confused with condyloma(warts).
Split papules appear at the angle or commissures of the mouth.
All secondary lesions are highly infectious with direct contact or palpation.
Without treatment, lesions of this stage relapse in about 20% of patients within a year.

15. Skin Findings Latent Syphilis
very few if any clinical signs of syphilis in this stage.

16. Skin Findings Tertiary Syphilis
Cutaneous gummas or granulomatous nodules develop subcutaneously, expand and ulcerate
These lesions also occur in the liver, bones and other organs Gummas produce a chronic inflammatory state in the body and produce distortion and malfunction with mass effects.
Untreated tertiary syphilis can also cause neuropathic joint discase and degeneration of bones.
Cardiovascular syphilis includes syphilitic aortitis, aortic aneurysm and cardiac valve problems.
Neurosyphilis can manifest as a generalized paresis,personality and emotional changes and hyperactive reflexes.
Infection and inflammation of the spinal cord can cause the characteristic shuffling gait of syphilis or tabes dorsalis.

17. Laboratory and Testing
Direct detection of treponemal spirochete is diagnostic
Detection of the spirochete from skin lesions can be achieved under dark-field microscopy, which shows corkscrew rotation motility of the small, spiral syphilis spirochete, but must not be confused with other spirochete infections
There are two quick and inexpensive serologic screening tests: the Rapid Plasma Reagin(RPR test ) and the Venereal Disease Research Laboratory (VDRL test) .
These screening tests are reactive by day 7 of the chancre,

18. Laboratory and Testing
Because of the possibilty of false positive results from the RPR and VDRL tests, positive results from the screening tests should be confirmed with a fluorescent treponemal antibody absorption test (FTA ABS) or the Treponemal pallidum hemaglutination assay (TPHA), which are more specific but more expensive.

19. Treatment
In early disease (primary, secondary, latent less than 1 year) the drug of choice is benzathine penicillin G 2.4 million units intramuscularly given once
In late disease (lasting more than 1 year) the drug of choice is benzathine penicillin G 2.4 million units intramuscularly once a week for 3 weeks consecutively.
People who are allergic to penicillin and not pregnant can be given doxycycline 100 mg twice a day for 2 weeks, or tetracycline, 500 mg four times a day for 2 weeks.

20. Treatment
successful therapy is indicated by a falling Rapid Plasma Reagin titer.
Rapid Plasma Reagin testing should repeated 3,6, and 12 months after be treatment is complete.
Treatment is repeated when there is a sustained fourfold increase in the Rapid Plasma Reagin titer.
Therapy is repeated when a high titer does not show a fourfold decrease within 1 year.
In most patients infected with the human immunodeficiency virus, syphilis responds to standard treatment regimens.

21. Chancroid Description
Chancroid is a rare sexualy tnansmitted disease caused by the Gram negative streptobacillus.
It is characterized by painful genital ulceration and inguinal lymphadenopathy.
The infection is also known as soft chancre and ulcus molle

22. Chancroid
History
The male to female ratio is 10 to 1 It is more common in heterosexual men, who obtain it from asymptomatic carriers, usually prostitutes
It is more common in developing countries and in people who travel to those countries but is rare in the United States.
The ulcer from chancroid is a risk factor for co-infection with human immunodeficiency virus.

23. Skin Findings
It has an incubation period from l day to 2 weeks from the time of initial infection
Most lesions occur on the genitalia, especially the coronal sulcus of the penis in men and fourchette and labia minora in women, but also includes the thighs, buttocks and perianal area
Half of men have a single ulcerative lesion, while women are more likely to have multiple lesions, but less pain
A painful red papule first appears at the site of inoculation within a day or 2. followed by a pustule, which may rupture, forming an ulcer with a bright red base.

24. Skin Findings
The ulcer of chancroid is deep, bleeds easily, is covered by a yellow to gray fibrinous exudate, and may spread laterally.
The ulcer sizes are variable from 3mm to 5cm in diameter.
Women are more likely to develop"kissing ulcers" or bilateral ulcers on opposing surfaces of the labia and perineal area.
These ulcers are highly infectious and may become multiple via autoinoculation. form of

25. Non-skin Findings Patients may feel ill with fever and malaise
Unilateral or bilateral inguinal suppurative lymphadenopathy in 50% about 1 week after infection
Lymph nodes may suppurate and ulcerate or resolve spontaneously
Women may carry the organism, but display no clinically detectable lesion and have no symptoms.
Women, more than men, may also present with dysuria or dyspareunia Untreated cases either resolve spontaneously or become chronic and require a long time to heal

26. Laboratory Haemophilus ducreyi cannot be cultured on routine media,
Newly formulated transport mcdia can maintain the viability of the organism.
A cotton swab is used to obtain a specimen at the base of the ulcer which is then rolled over a glass slide.

27. Laboratory
Gram-negative clumped organisms, resembling a school of fish can be scen and is diagnostic
There is a high rate of coinfection with human immunodeficiency virus among patients with chancroid, so a test for this virus is reasonable in these patients
Syphilis serologies should be considered Differential Diagnosis Herpes simplex Syphilis lymphogranuloma venereum Granuloma inguinale

28. Treatment Azithromycin 1g orally in a single dose
Ciprofloxacin 500mg twice daily for 3 days
Ceftriaxone 250 mg intramuscularly in single dose,
Erythromycin base 50omg orally four times daily for 7 days.